candida albicans (yeast)

miconazole, clotrimazole

fluconazole weekly if persistent vaginitis

amphotericin B or capsofungin if severe

+- Fluconazole if mild

potassium hydroxide (KOH) smear : budding yeast/hyphae

often clinical diagnosis

meningioencephalitis 

(cryptococcosis)

meningioencephalitis 

(cryptococcosis)

India ink stain : cryptococcoal antigen in CSF is seen

+ blood cultures in patients with HIV

fluconazole if CD4 < 50 

cryptococcosis considered AIDS defining illness

yeast

histoplasmosis

increased ALP, increased LDH,

+ blood cx if disseminated w/ HIV

pancytopenia, sputum cx, Ag by PCR

intraconazole (mid-moderate dz)

amphotericin B (severe or failed Intraconazole)

pneumocystitis jiroveci (formerly carinii)

yeast like fungus (doesn't respond to antifungals)

CXR : bilateral diffuse interstitial infiltrates

increased LDH (>200U/L); fluid specimens

trimethoprim-sulfamethoxazole DOC

add prednisone if O2 sat < 80%

Clindamycin + Primaquine

Trimetrexate

Dapsone

gram positive rod

diphtheria 

rare in US d/t vaccination 

inhalation of respiratory secretions

exotoxin induces inflammatory response

1. pseudomembranes: friable gray/white membrane on pharynx that bleeds if scraped 

2. bull neck: neck swelling d/t enlarged cervical lymphadenopathy

3. fevers & nasopharyngeal sx

4. may cause myocarditis & neuropathy (exotoxin induced inflammatory response) 

diphtheria antitoxin (horse serum) + erythomycin or PCN x 2 weeks

erythromycin given to close contacts

gram positive rod

tetanus

neurotoxin (tetanospasmin) blocks neuron inhibition --> severe muscle spasm

toxin blocks the release of ACH leading to Ach-mediated sustained contrations @ the NM joint

metronidazole or PCN G + tetanus IG (ex. 5,000 units)

&

Diazepam (benzo to reduce spasms)

Tdap, Td (vaccine) q10y

(given if major cut occur > 5 yr since last booster)

Tetanus IG 250u given if never immunized (w/ initiation of tetanus toxoid vaccine)

botulism

gram positive spore forming rods

h/o ingestion of canned/smoked/vacuum-packed foods; 

IVDA (intravenous drug abuse)

ingestion of honey

sx occur 6-8h after ingestion

Sudden onset of 7 D's : diplopia, dry mouth, dysphagia, dysarthria, dysphonia, decreased muscle strength, dilated, fixed pupils --> paralysis 

GI symptoms (N/V). CN palsies

1. antitoxins in all cases.

2.Respiratory support: intubation if respiratory failure

3. cathartics to remove toxins.  No abx in foodbourne type (may worsen)

4. antibiotics ONLY used in wound botulism: PCN G, chloramphenicol, clindamycin 

pelvic inflammatory disease (PID)

reactive arthitis (Reiter's syndrome)

Lymphogranuloma venereum 

1 g Azithromycin (1 time dose) 

or

Doxycycline 100 mg BID x 10 days

re-test in 3 weeks to ensure clearance

also tx for gonorrhea

urethritis & cervicitis 

dissemination: Arthritis-dermatitis syndrome 

dissemination: arthritis -dermatitis syndrome

can turn into septic arthritis (es knee)

ceftriaxone 250 mg IM, Cefixime

tx for chlamydia

catarrhal phase: URI symptoms 1-2 weeks

paroxysmal phase: severe paroxysmal coughing fits (w/ whooping sound during inhalation after cough fit) w/ post vomiting emesis

convalescent phase: resolving of symptoms (after about 1 month of the onset of sx

nasopharyngeal swab 

(if done in first 3 weeks of sx onset)

strikingly increased lymphocytosis

pneumonia

encephalopathy & seizures

increased mortality rate in infants d/t apnea /cerebral hypoxia as a result of prolonged coughing fits

erythromycin DOC 

bactrim 2nd line agent

treatment generally ineffective @ changing clinical course but decreases contagiousness

Tdap used for booster tetanus shots to revaccinate 

syphilis

lyme disease

rocky mountain spotted fever

chancre

2ndary = maculopapular rash

3ry: gumma 

argyll robertson pupil 

3ry syphilis

PCN G 

tetracycles, macrolides, ceftriaxone if PCN allergic

early localized

early disseminated

late disease

erythema migrans (90%)

expanding, warm annular erythematous rash (classically seen with central "bullseye" usually within a month of & around area of tick bite

usually 7-10 d after bite

may be accompanied w/ viral like syndrome

1-12 weeks

rheumatologic arthritis (esp large joints)

multiple EM 

neurologic (h/a, meningitis, weakness, Bells palsy, neuropathy)

cardiac (AV block)

persistent synovitis

persistent neurological symptoms

clinical (presence of EM, h/o tick bite, arthritis)

ELISA (serologic testing) positive by 3rd week

doxycycline

amoxicillin (DOC in children < 9 y) x 2-3 weeks

cefuroxime

IV ceftriaxone if 2nd/3rd AVC, syncome, dyspnea,CP, or CNS dz (other than Bell's palsy)

doxycycline 200 mg x 1 dose within 72 h 

if ixodes tick @ least 36h & >20% ticks infected in area

fevers, HA, N/V, lethargy --> red maculopapular rash FIRST on wrists/ankles --> spreading centrally over 2-3 days (palms/soles characteristic) ==> petechiae 

clinical (don't wat for serologies)

skin bx, thrombocytopenia, hyponatremia

CSF: low glucose & pleocytosis increased cell count

immunofluorescent assay for antibodies

toxoplasma gondii (protozoan)

toxoplasmosis

1. primary infections are usually asxatic in IC patient or mono-like illness with cervical lymphadenopathy

2. encephalitis & chorioretinitis in IC patients (CD4 < 100); fever, lymphadenopathy (esp. cervical), malaise, HA, myalgias, arthritis

3. congenital: part of the ToRCH syndrome; blueberry muffin rash (TTP), hepatosplenomegaly, hearing loss, mental retardation

toxoplasmosis

rubella

cytomegalovirus

Herpes simplex 2

PCR

head CT scan may show ring-enhancing lesions but may also be seen w CNS lymphoma 

Sulfadiazene (or clindamycin) + pyrimethamine (w/ folinic acid/leucovorin to prevent bone marrow suppression & reduce nephrotoxicity) 

Spiramycin if pregnant 

Herpes simplex virus 

cytomegalovirus (HHV 5)

varicella zoster virus (HHV 3)

Epstein Barr virus (infectious mononucleosis)

rabies

Human immunodeficiency virus (HIV) 

HSV 1 - oropharyngeal

HSV 2 - genital 

HSV 3 - varicella zoster

HSV 4 - epstein barr

HSV 5 - CMV

HSV 6 - roseola

HSV 7 - pityriasis rosea

HSV 8 - Kaposi sarcoma

oral (acute herpetic gingivostomatitis, herpes labialis, & acute herpetic pharngotonsillitis)

genital

herpes keratitis

bells palsy

HSV esophagitis

herpetic whitlow

encephalitis

primary infxn in children

sudden onset of fever, anorexia - gigivitis (gum swelling, friable/bleeding gums); vesicles in mouth, tongue & lips - grey/yellow lesions

primary infx in adults

vesicles that rupture - ulcerative lesions with grayish exudates in posterior pharyngeal mucosa

2ry infection most often HSV 1 

cold sore, fever blister with stress/illness

tzank smear: intranuclear inclusion bodies & multinucleated giant cells

PCR most sensitive and specific test

sensorineural hearing loss common & blueberry muffin rash (TTP) petechiae

hepatosplenomegaly, mental & motor dysfunction

retinitis

esophagitis

scambled eggs/ketchup appearance (pizza pie) on fundoscopy (hemorrhage w/ soft exudates)

seen if CD4 < 50

pneumonitis, encephalitis; CMV colitis (CD4 < 100)

odynophagia

large superficial ulcers on EGD

serologies (antigen tests, IgM, IgG titers) 

owl's eye apperance on biopsy of tissues

ganciclovir DOC, or foscarnet, Cidofovir

owl's eye

seen with CMV

varicella (check pox)

herpes zoster (shingles)

herpes zoster ophthalmics

herpes zoster oticus (Ramsay-Hunt Syndrome)

Post herpetic neuralgia

primary inection

fevers, malaise

clusters of vesicles on erythematous base "dew drops on  rose petal"

Different stages

At any given time beginning on the face, trunk -- extremities

usually more severe in adults

shingles involving 1st division of trigeminal nerve (CN V)

Hutchinson's sign : lesions on nose usually heralding ocular involvement 

Dendritic lesions seen on slit lamp exam if keratoconjunctivitis present

VZV reactivation along one dermatme

reactivation of dormant lesion in spinal root & CN ganglia

disseminated in HIV

facial nerve (CN VII)

otalgia, lesions on ear, auditory canal & TM, facial palsy

auditory sx: tinnitius, vertigo, deafness, ataxia 

pain > 3 months

herperasthesias or decreased sensation

gabapentin or TCA

topical (lidocaine gel, capsaicin)

bacterial infection MC 

PNA

encephalitis

Guillain Barre syndrome

saliva "kissing disease'

esp young adults 15-25y

HHV 4 

80% of adults seropositive

fever 

sore throat (+- exudative)

posterior cervical lymphadenopathy

splenomegaly

petechial rash in 5% (esp if given ampicilin)

Hodgkins lymphoma 

may cause Burkitt's lymphoma & CNS lymphoma in AIDS patients

heterophili (monospot) Ab test (positive within 4 wks)

PBS: >50% lymphocytes w/ > 10% atypical lymphocytes

rapid viral capsid antigen test

supportive (rest, analgesics, antipyretics)

sx may last for months

steroids used ONLY if airway obstruction d/t lymphadenpathy, severe thrombocytopenia, or hemolytic anemia 

infected saliva from bites of rabid animals : raccoons, bats, skunks, foxes, wolves

dogs cause > 90% in developing countries

NOT rodents (only rodent that will survive long enough is a woodchuck)

virus goes through axons from peripheral to CNS

prodrome

CNS phase

respiratory phase

prodrome - pain, paresthesias, itching @ initial site

CNS phase - encephalitis, hydrophobia (painful laryngospasm with drinking liquids). Patients may become sensitive to air currents (aerophobia) and changes of temperture. May develop rabid rage, foaming @ the mouth w/ thick sputum 

Respiratory phase: respiratory muscle paralysis leading to death

negri bodies in brain of dead animals (esp in hippocampus)

animals observed 7-10 days

once sx occurs, patients rarely survive

coma induction, amantadine & ribavirin

HDCV (Rabies Vaccine) day 0,3,7,14 + Rabies immune globulin 1/2 wound, 1/2 IM.

ideally started within 6 days of bite

if IC, include day 28 in the HDCV vaccine schedule

retrovirus

changes viral RNA into DNA via reverse transcriptase

HIV 1 & 2

sexual intercourse

IV drug use (shared needles, ect)

mother to child transmission (birth or breast feeding)

recepit of blood products before 1985

mucosal contact with infected blood 

needle stick injuries

1. acute seroconversion : flu-like illness - fever, malaise, generalized rash, generalized lymphadenopathy

2. AIDS 

recurrent severe & potentially life-threatening opportunistic infections or malignancies

HIV wasting syndrome (chronic diarrhea & weight loss)

AIDS- associated neurologic changes (encephalopathy & dementia)

1. antibody testing - ELISA, rapid testing (blood or saliva)

2. western blot: confirmatory test

3. HIV RNA viral load 

fecal/oral contamination

highly virulent

IP : 1-7 days

S. Sonneii MC in US

Gram neg rod

crampy lower abdominal pain

high fever

tenesmus (straining)

explosive watery diarrhea -> mucoid, bloody

severe cases - toxic mega colon

Neurologic manifestatsions esp in young children (febrile seizures)

may cause leukemoid rxn (WBC > 50,000)

stool cx

fecal WBC/RBC's

sigmoidoscopy: punctuate areas of ulceration

trimethoprim-sulfamethomazole tx of choice

fluoroquinolones

poultry products (dairy, meat, eggs)

exotic pets (reptiles ex turtles)

feco-oral

IC states

sickle cell disease (increased risk of osteomyelitis w/ Salmonella)

post splenectomy pts

AIDs

children

elderly

1. salmonella gastroenteritis

2. typhoid (enteric) fever

 Abd pain, fever, cramping.  mucous diarrhea.

"Pea soup stools" (watery brown-green)

usually self-limited, vomiting

S. typhi

(type of salmonella)

cephalic phase: HA, constipation, pharyngitis, cough --> diarrhea (Pea soup stools)

Intractable fever, relative bradycardia

crampy abd pain, hepatosplenomegaly

blanching "Rose Spots" appears in 2nd week

Pts will have + blood cx for salmonella & leukopenia

(type of salmonella)

fluoroquinolones, ceftriaxone x 2 weeks if severe

(tx salmonella gastroenteritis & typhoid (enteric) fever)

stool gram stain--> gram neg rods

PCR for toxinogenic strains

rehydration

abx - doxycycline

fluoroquinolone if resistant

protozoa 

helminths (worms) 

 do not reproduce in host

may cause eosinophilia

ex. round worms, trematode (flukes), hook worms, tape worms

reproduce in host

fecal-oral

ex. giardia lamblia

sudden onset, short duration bacterial or GI symptoms

bloating, excessive gas, intermittent diarrhea w/o blood usually is Giardia

extraintestinal sxs are uncommon

weight loss

anemia w/ hookworm infections

N/V intermittent, recurrent

abd. pain/tenderness

Pruritis ani: E vermicularis, T. trichiura

parasite seen on stool microscopy

tissue bx of intestine, liver, or bladder may show granulomatous rxns of schistosome eggs

food poisoning

malabsorption to lactose or gluten

IBS

hemorrhoid or rectal fissure

avoid drugs that limit intestinal motility

symptomatic tx

drug choice depends on parasite

metronidazole or tinidazole or furazolidone 

(parasitic infx)

bactrim

(parasitic infx)

tetracycline or iodoquinol or metronidazole

(parasitic infx)

mebendazole

(helminth infx)

praxiquantel

(helminths infx)

niclosamide

(helminths infx)

incubation period of 1-4 days

fever, chills, malaise, substernal soreness, HA, nasal stuffiness, occasional nausea

fever lasts 1-7 days (over 100.7)

coryza (nonproductive cough) & ST

leukopenia

proteinuria

rapid immunoluorescence assays & enzyme immunoassays are becoming more popular

necrosis of respirator epithelium

bacterial infections

pneumonia

Reye syndrome

fatty liver w/ encephalopathy

rapid liver failure

associated with ASA use

2-3 weeks after onset of viral infection

(associated with influenza)

bed rest

zanmivir 10 mg (2 inhalations) BID for 5 days - CI asthma

oseltamivir 75 mg BID x 5 days

meds only effective if given early (w/n 48 hrs)

Do not use abx